Exhibits
Click to highlight the findings that indicate the client is stable for discharge.
The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning.
She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.
Assessment
Neurological Alert and oriented times 4. Cardiovascular WNL
Respiratory WNL
Gastrointestinal/Genitourinary Voided twice throughout night
ambulated 100 yards (91 meters) last night and 200 yards
pain rating of 2
tolerated fluids
Alert and oriented times 4
Voided twice
Respiratory WNL
Cardiovascular WNL
no nausea or vomiting
The Correct Answer is ["A","B","C","D","E"]
The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning. She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.
Assessment
Neurological Alert and oriented times 4.
Cardiovascular WNL
Respiratory WNL
Gastrointestinal/Genitourinary Voided twice throughout night
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A:While a voiding diary can be useful for monitoring urinary symptoms, the client’s description of urinary retention symptoms requires immediate assessment for bladder distention or obstruction, not just recording voiding patterns.
B: Obtaining a urine specimen is important if a urinary tract infection is suspected, but the symptoms described are more indicative of urinary retention, possibly due to prostate issues, which requires immediate physical assessment.
C:The client’s symptoms suggest urinary retention, which can be detected by palpating the suprapubic area for bladder distention. This is the most immediate assessment to determine if the client has retained urine in the bladder.
D: Cleansing the glans penis is important for hygiene and may prevent infections, but it does not address the underlying issue of bladder fullness and urinary retention.
Correct Answer is D
Explanation
A. Assisting the client to recall everyone possibly exposed since the onset of symptoms is important for contact tracing but is not the most immediate action to take.
B. Teaching the client to wear a mask, hand wash, and social distance to prevent spreading the virus is important for infection control but does not address the immediate need to prevent
potential transmission to others in the clinic setting.
C. Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is appropriate for specimen handling but does not address the need for immediate infection control measures for the client and others in the clinic setting.
D. Moving the client to a private room, keeping the door closed, and initiating droplet precautions is the most important action to take to prevent potential transmission of COVID-19 to others in the clinic setting, given the client's symptoms and recent travel history.
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